HEALTH EXAMINATION FORM

Name __________________________________ Birth Date __________ Age ___

Parent or Guardian ___________________________ Phone _______________
Home Address ______________________________________________________
In case of emergency notify _________________________________________
Address ____________________________________________________________
HEALTH HISTORY: (Check by giving appropriate date)
Frequent colds _____________ Kidney Trouble ______________ Chickenpox____________
Abscessed Ears _________________ Convulsions _______________ Mumps _____________
Fainting ____________ Sleep Walking ______________ Whooping cough _______________
Frequent Sore Throat _________________________ Heart trouble _____________________
Sinusitis ___________________ Measles ____________________ Bronchitis _______________
Athlete’s Foot _______________________ Stomach upsets _____________________________
Constipation_________________________ Tuberculosis _______________________________
Operations or other serious injuries _______________________________________________
Allergic Reactions :
Penicillin : ___________________________ Other drugs: __________________________
Details of the above or additional information______________________________________

Any specific activities to be encourage? ___________________________________________

RESTRICTED _____________________________________________________________________

General condition: ________________________________________________________________

Physician: ________________________________________________________________________

IMPORTANT: Please notify the Training/Camp Staff is this applicant is exposed

to any communicable disease during the three weeks prior to camp attendance.
 PARENTS CONSENT FORM PARENTS CONSENT FORM

TO WHOM THIS MAY CONCERN: TO WHOM THIS MAY CONCERN:

This is to permit my daughter This is to permit my daughter

____________________________________
of _____________________________ to
participate in the
_____________________________________
_____________________________________
________________________ to be held at
_____________________________________
_____________ on ___________________.
____________________________________
of _____________________________ to
participate in the
_____________________________________
_____________________________________
________________________ to be held at
_____________________________________
_____________ on ___________________.

We will not hold the Girl Scouts of the We will not hold the Girl Scouts of the
Philippines-Quezon Council responsible for Philippines-Quezon Council responsible for
any untoward incident that may happen any untoward incident that may happen
beyond their control. beyond their control.

_____________________________ _____________________________
Parent’s Printed Name & Signature Parent’s Printed Name & Signature

Noted: Noted:
_______________________ _______________________
Troop Leader Troop Leader

PARENTS CONSENT FORM

TO WHOM THIS MAY CONCERN:

This is to permit my daughter

____________________________________
of _____________________________ to
participate in the
_____________________________________
_____________________________________
________________________ to be held at
_____________________________________
_____________ on ___________________.

We will not hold the Girl Scouts of the

Philippines-Quezon Council responsible for
any untoward incident that may happen
beyond their control.

_____________________________
Parent’s Printed Name & Signature

Noted:
_______________________
Troop Leader
CAMP APPLICATION FORM FOR GIRLS
District:____________________ Council: QUEZON Region: SOUTHERN LUZON

PERSONAL DATA
Name:
Last First Middle
Date of Birth:
Home Address: Tel. No.:
School: Year:
Parents/Guardian: